1912093816 NPI number — CARA A GRAVLIN ACNP

Table of content: CARA A GRAVLIN ACNP (NPI 1912093816)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912093816 NPI number — CARA A GRAVLIN ACNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GRAVLIN
Provider First Name:
CARA
Provider Middle Name:
A
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
ACNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CROWE
Provider Other First Name:
CARA
Provider Other Middle Name:
A
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1912093816
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/26/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 W KENWOOD AVE LOWR LEVEL
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DECATUR
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
62526-4368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
217-545-8000
Provider Business Mailing Address Fax Number:
217-545-4485

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 W KENWOOD AVE LOWR LEVEL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DECATUR
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
62526-4368
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
217-545-8000
Provider Business Practice Location Address Fax Number:
217-545-4485
Provider Enumeration Date:
10/05/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LA2100X , with the licence number:  209-005882 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)